Research on high quality health care needs to move beyond what to how
Authors: Ashish KC, Peter Waiswa, Mary V Kinney
Journal: The Lancet Global Health (2023)

Health system quality has received much attention since The Lancet Global Health Commission on high quality health systems in 2018, which proposed new ways to define, measure, and improve the performance of health systems.1Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1123) Google Scholar Factors influencing quality of health systems are well known, both as inputs and processes, including WHO's six building blocks (service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership and governance),2Jordan K Marten R Gureje O Daelmans B Kruk ME Where is quality in health systems policy? An analysis of global policy documents.Lancet Glob Health. 2018; 6: e1158-e1161Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar but we still need to think how to measure them.3George A LeFevre AE Jacobs T et al.Lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus.BMJ Glob Health. 2019; 4e001316Crossref Google Scholar Leadership and governance is arguably the most important building block, but few large-scale, quantitative studies include health system governance components when assessing primary care level health system quality in low-income and middle-income countries (LMICs).4Gilson L Lehmann U Schneider H Practicing governance towards equity in health systems: LMIC perspectives and experience.Int J Equity Health. 2017; 16: 171Crossref PubMed Scopus (34) Google Scholar, 5Coles E Anderson J Maxwell M et al.The influence of contextual factors on healthcare quality improvement initiatives: a realist review.Syst Rev. 2020; 9: 94Crossref PubMed Scopus (45) Google Scholar The study by Todd P Lewis and colleagues in The Lancet Global Health aims to close this evidence gap by assessing health service quality in six LMICs, highlighting the system determinants of primary health care by analysing data from Service Provision Assessments (SPAs).6Lewis TP McConnell M Aryal A et al.Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysis.Lancet Glob Health. 2023; 11: e862-e870Summary Full Text Full Text PDF Scopus (1) Google Scholar The authors apply a positive deviance approach comparing service provision in the best performing (top 10%) and worst performing (bottom 50%) health facilities (both hospitals and clinics). The aim is to identify facility-level factors that explain the performance gap across four dimensions of performance: population factors, governance factors, workforce factors, and tools. Although all four dimensions were significantly associated with best performance among the clinics, only tools were slightly better in best performing hospitals. The private-for-profit hospitals and clinics were significantly better performing than government owned facilities. The authors conclude that high quality governance, management, and community engagement are associated with best performance; yet the multivariable adjustment showed governance as a minimally contributing factor of best performance compared with workforce and tools. Lewis and colleagues’ study further validates what is known about factors that influence health system quality.5Coles E Anderson J Maxwell M et al.The influence of contextual factors on healthcare quality improvement initiatives: a realist review.Syst Rev. 2020; 9: 94Crossref PubMed Scopus (45) Google Scholar, 7Zamboni K Baker U Tyagi M Schellenberg J Hill Z Hanson C How and under what circumstances do quality improvement collaboratives lead to better outcomes? A systematic review.Implement Sci. 2020; 15: 27Crossref PubMed Scopus (63) Google Scholar, 8Institute for Health Metrics and EvaluationAccess, bottlenecks, costs, and equity (ABCE). Institute for Health Metrics and Evaluation, Seattle, WA2011Google Scholar It will be interesting to see whether these results will challenge implementation science practitioners on how to improve health systems with different methods or whether it will advance measurement approaches for monitoring improvement. There are different lenses through which to understand and measure health system quality drivers, some of which unpack the more tangible factors (service delivery lens) and some of which tackle the more complex factors, such as the attributes of the actors and the context (social and system lenses), while considering different health system levels.3George A LeFevre AE Jacobs T et al.Lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus.BMJ Glob Health. 2019; 4e001316Crossref Google Scholar Lewis and colleagues assessed the health system quality drivers and their association with system performance. The authors are to be commended for using existing datasets to avoid duplication and for applying a positive deviant approach, as we should be wary of investing in more large-scale studies that tell us what we already know. There are several limitations to Lewis and colleagues’ study. First, more consideration is needed about using the SPA to measure health system quality, including if these measures can be validated and correctly used. For example, in Lewis and colleagues’ study external supervision was assigned as a measure of governance and supportive supervision was assigned to workforce, and both external supervision and supportive supervision measures were significantly different between best-performing and worst-performing facilities. Second, the authors did not analyse middle-performing health facilities, so there is no understanding of the transition of health system functions between performance levels. Third, this was a large-scale, cross-sectional survey, in which health system function measures, such as client feedback mechanisms, management meetings, quality assurance, and promotion opportunities, are assessed through semi-structured interviews rather than longitudinal observations and qualitative interviews. Fourth, the SPAs are limited to a checklist approach and do not capture the more nuanced realities of practice and governance.3George A LeFevre AE Jacobs T et al.Lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus.BMJ Glob Health. 2019; 4e001316Crossref Google Scholar Fifth, the SPAs do not use hierarchical modelling to quantify the change in gradients in clinical care when the different measure scores are adjusted. Sixth, the authors did not draw on the wealth of knowledge in health policy and system research, including seminal papers on governance, leadership, and management.4Gilson L Lehmann U Schneider H Practicing governance towards equity in health systems: LMIC perspectives and experience.Int J Equity Health. 2017; 16: 171Crossref PubMed Scopus (34) Google Scholar, 9Schneider H George A Mukinda F Tabana H District governance and improved maternal, neonatal and child health in South Africa: Pathways of Change.Health Syst Reform. 2020; 6e1669943PubMed Google Scholar, 10Gilson L Everyday politics and the leadership of health policy implementation.Health Syst Reform. 2016; 2: 187-193Crossref PubMed Scopus (37) Google Scholar Delivering health care is challenging and complex, especially in low-resource settings. Investing in the everyday practice of governance will be crucial as human resources and tools can be translated into good processes and outputs through effective governance.4Gilson L Lehmann U Schneider H Practicing governance towards equity in health systems: LMIC perspectives and experience.Int J Equity Health. 2017; 16: 171Crossref PubMed Scopus (34) Google Scholar In the Sustainable Development Goal era, health system researchers need to go beyond identifying what factors influence quality of care and start to identify how to change quality of care. Using the suggested new approach of comparing best performers with worst performers and context-specific investigation could be an entry point. What is needed for high quality health systems is a contextual understanding of what works and why in order to determine how to better implement change within each setting. We declare no competing interests. Health service quality in 2929 facilities in six low-income and middle-income countries: a positive deviance analysisOur findings suggest that best-performing health facilities are characterised by good management and leaders who can engage staff and community members. Governments should look to best performers to identify scalable practices and conditions for success that can improve primary care quality overall and decrease quality gaps between health facilities. Full-Text PDF Open Access